Radiation Safety
Baltimore, MD 21201
University of Maryland, Baltimore
410-706-7055 Voice
410-706-8212 Fax
Radiation Worker Registration Form
Fields in BOLD are Required

Type of Registration:

Last Name: First Name:  MI: 
Soc. Sec. No.:  (123-45-6789) Birthdate:  (i.e., 02/16/1963)
Gender:  Male Female
Job Title: 
Division/Department:          Bldg.: Rm. No.:
Work Phone: Fax:  Email: 

Home Address (for exposure report distribution only)

Street:  City:  State:  Zip: 

PLEASE ANSWER ALL QUESTIONS OR STATEMENTS BY CHECKING ALL THAT APPLY

1. Have you previously used radiation dosimeters at any location? 

If Yes, record name, address and contact person where dosimetry was previously used...............................>
No
Company/Institution Name:
Department & Supervisor:
Street Address/P.O. Box:
City State   Zip:
Dates of Employment:

2. Do you currently use radiation dosimeters at any of the following locations? 


Other location: 

If Yes, record name, address and contact person where radiation dosimetry is currently being used.....................................>

 Yes   or  No
Company/Institution Name:
Department & Supervisor:
Street Address/P.O. Box:
City State   Zip:
Dates of Employment:
***Please note that you are required to notify Radiation Safety if you are now, or later become a radiation worker at another company/institution. This information is needed to accurately track radiation exposure.

3. If you answered 'YES' to No. 2, will dosimetry be continued after beginning work at UMB? 
Yes No N/A

4. Do you work with any of the following radioactive materials or radiation producing machines?
(choose "None" if applicable, do not leave blank)>:
(Hold down the ctrl key to select more than one item)
5. Ring Profile: 
Dominant hand:  Right     Left     N/A
Ring size:  Small     Medium     Large

6. The UMB dosimetry policy specifies that radiation workers must be issued dosimeters if they are expected to receive 100 millirem in a year. The Radiation Safety Office will review your expected exposure and determine if you will be required to wear a dosimeter based on policy guidelines. Radiation workers may voluntarily wear dosimeters for their own information, but will be required to abide by all dosimetry policies should they choose to do so.
Do you wish to receive a dosimeter even if Radiation Safety may not require you to do so? Yes or No

This is to certify that to the best of my knowledge, the information contained herein is complete and accurate and to authorize the release of my radiation exposure and bioassay history and other pertinent information to the University of Maryland, Baltimore.

Authorized User/Dosimetry Coordinator:  

Authorization/Series Number: 

Date Submitted:

Revised: 6/20/05